Impact of epilepsy on employment status: findings from a UK study of people with well-controlled epilepsy

Disability burden of epilepsy in Türkiye: How does it differ from other newly industrialized countries?

INTRODUCTION

Epilepsy accounts for a substantial part of the global burden of disability. This study aimed to investigate the employment history of people with epilepsy in Türkiye, evaluate the role of education level in employment and epilepsy burden, and compare epilepsy employment data in different societies according to sociodemographic index data.

METHODS

This prospective study included 420 people 16-76 years of age who were diagnosed with epilepsy according to the criteria of the International League Against Epilepsy. Socioeconomic, clinical, and employment data were collected using a questionnaire in face-to-face interviews.

RESULTS

The study sample was 52 % women, the mean age was 34.2 ± 12.7 years (range: 16-76 years), and the mean disease duration was 17.2 ± 12.6 years. Only 26.7 % (n = 112) of the participants were actively working, 38.8 % had never worked, and 64.5 % had changed jobs at least twice (mean 2.45 job changes). The unemployment rate among the study sample was 7 times higher than in the general population. Female gender, low self and parental education levels, high seizure frequency, and the use of multiple anti-seizure medications were significantly associated with lower employment.

CONCLUSION

We determined that the employment rates and education levels of people with epilepsy in Türkiye are low, the unemployment rate is high, and the burden of epilepsy is higher when compared with other low-middle income and newly industrialized countries and national population data. Education and employment opportunities for people with epilepsy in Türkiye should be improved to reduce the burden of epilepsy-related disability and thereby increase quality of life, welfare, and psychosocial well-being in this group.

Epilepsy first aid awareness among healthcare workers in Saudi Arabia: A cross-sectional study

Objectives

Epilepsy is a neurological disorder affecting more than 50 million human lives of all ages, its social, physical and psychological implications is of huge concern. The current study and as a continuation of epilepsy knowledge assessment projects conducted by our research team is aimed to assess the knowledge of healthcare workers regarding epilepsy first aid in Saudi Arabia.

Methods

A cross-sectional questionnaire-based study was carried out from 2020 to 2021.

Results

During the study period, 272 healthcare workers were recruited; participants were males and females from different nationalities in various Saudi Arabian cities, possess diverse qualifications, and belong to several healthcare-related professions. The question, "Did you witness an epileptic seizure"? was answered as "Yes" by 42% of participants, and in response to the question "If you know that this patient struggles during seizure attacks," 58% of respondents stated that they would not call an ambulance. Moreover, the question "Put something in his/her mouth to prevent tongue biting" was incorrectly answered as "Yes" by 42% of respondents, and the question "Try to catch him/her and stop his/her movement" in order to control the attack was answered "Yes" by 21% of respondents. Furthermore, almost 90% of healthcare participants do not know how to use the Vagus Nerve Stimulation device. The mean knowledge score among participants was 23.7; sex, as well as type of higher qualification obtained, was found to be significantly associated with the score of knowledge.

Conclusion

Knowledge toward epilepsy and epilepsy first aid among healthcare workers in Saudi Arabia was found fragile. Further research is appreciated to support the current findings.

Systematic review of frequency of felt and enacted stigma in epilepsy and determining factors and attitudes toward persons living with epilepsy-Report from the International League Against Epilepsy Task Force on Stigma in Epilepsy

OBJECTIVE

To review the evidence of felt and enacted stigma and attitudes toward persons living with epilepsy, and their determining factors.

METHODS

Thirteen databases were searched (1985-2019). Abstracts were reviewed in duplicate and data were independently extracted using a standardized form. Studies were characterized using descriptive analysis by whether they addressed "felt" or "enacted" stigma and "attitudes" toward persons living with epilepsy.

RESULTS

Of 4234 abstracts, 132 met eligibility criteria and addressed either felt or enacted stigma and 210 attitudes toward epilepsy. Stigma frequency ranged broadly between regions. Factors associated with enacted stigma included low level of knowledge about epilepsy, lower educational level, lower socioeconomic status, rural areas living, and religious grouping. Negative stereotypes were often internalized by persons with epilepsy, who saw themselves as having an "undesirable difference" and so anticipated being treated differently. Felt stigma was associated with increased risk of psychological difficulties and impaired quality of life. Felt stigma was linked to higher seizure frequency, recency of seizures, younger age at epilepsy onset or longer duration, lower educational level, poorer knowledge about epilepsy, and younger age. An important finding was the potential contribution of epilepsy terminology to the production of stigma. Negative attitudes toward those with epilepsy were described in 100% of included studies, and originated in any population group (students, teachers, healthcare professionals, general public, and those living with epilepsy). Better attitudes were generally noted in those of younger age or higher educational status.

SIGNIFICANCE

Whatever the specific beliefs about epilepsy, implications for felt and enacted stigma show considerable commonality worldwide. Although some studies show improvement in attitudes toward those living with epilepsy over time, much work remains to be done to improve attitudes and understand the true occurrence of discrimination against persons with epilepsy.

Remote and Long-Term Self-Monitoring of Electroencephalographic and Noninvasive Measurable Variables at Home in Patients With Epilepsy (EEG@HOME): Protocol for an Observational Study

Background

Epileptic seizures are spontaneous events that severely affect the lives of patients due to their recurrence and unpredictability. The integration of new wearable and mobile technologies to collect electroencephalographic (EEG) and extracerebral signals in a portable system might be the solution to prospectively identify times of seizure occurrence or propensity. The performances of several seizure detection devices have been assessed by validated studies, and patient perspectives on wearables have been explored to better match their needs. Despite this, there is a major gap in the literature on long-term, real-life acceptability and performance of mobile technology essential to managing chronic disorders such as epilepsy.

Objective

EEG@HOME is an observational, nonrandomized, noninterventional study that aims to develop a new feasible procedure that allows people with epilepsy to independently, continuously, and safely acquire noninvasive variables at home. The data collected will be analyzed to develop a general model to predict periods of increased seizure risk.

Methods

A total of 12 adults with a diagnosis of pharmaco-resistant epilepsy and at least 20 seizures per year will be recruited at King’s College Hospital, London. Participants will be asked to self-apply an easy and portable EEG recording system (ANT Neuro) to record scalp EEG at home twice daily. From each serial EEG recording, brain network ictogenicity (BNI), a new biomarker of the propensity of the brain to develop seizures, will be extracted. A noninvasive wrist-worn device (Fitbit Charge 3; Fitbit Inc) will be used to collect non-EEG biosignals (heart rate, sleep quality index, and steps), and a smartphone app (Seer app; Seer Medical) will be used to collect data related to seizure occurrence, medication taken, sleep quality, stress, and mood. All data will be collected continuously for 6 months. Standardized questionnaires (the Post-Study System Usability Questionnaire and System Usability Scale) will be completed to assess the acceptability and feasibility of the procedure. BNI, continuous wrist-worn sensor biosignals, and electronic survey data will be correlated with seizure occurrence as reported in the diary to investigate their potential values as biomarkers of seizure risk.

Results

The EEG@HOME project received funding from Epilepsy Research UK in 2018 and was approved by the Bromley Research Ethics Committee in March 2020. The first participants were enrolled in October 2020, and we expect to publish the first results by the end of 2022.

Conclusions

With the EEG@HOME study, we aim to take advantage of new advances in remote monitoring technology, including self-applied EEG, to investigate the feasibility of long-term disease self-monitoring. Further, we hope our study will bring new insights into noninvasively collected personalized risk factors of seizure occurrence and seizure propensity that may help to mitigate one of the most difficult aspects of refractory epilepsy: the unpredictability of seizure occurrence.

International Registered Report Identifier (IRRID)

PRR1-10.2196/25309

Knowledge, attitude, and believes of epilepsy in local communities of Saudi Arabia

Aim of the Study

To assess public knowledge, attitude, and believes toward the epilepsy among local community populations in Shaqra Area, Kingdom of Saudi Arabia.

Methods

An organized 14 questionnaire was prepared to analyze public knowledge attitudes and believes about epilepsy. Study was conducted randomly in common public places in Shaqra City, Saudi Arabia, during the months of April and May 2016. Sample size includes 155 males and 130 females from Shaqra City of Saudi Arabia.

Results

The study analyzed the 285 local public including 155 male and 130 female contributors. About 68.38% male contributors and 63.07% female contributors studied Diploma or Bachelor education program. Female contributors (71.53%) were aware about epilepsy as compared with male contributors (58.70%). Maximum number of female contributors (82.30%) believes that epilepsy is treated by medication as compared with male contributors (58.70%).

Conclusion

The knowledge, awareness, and attitudes of the epilepsy are found to be much improved in local community of Saudi Arabia. In the modern era, people assume that epilepsy is still due to evil spirit. Many contributors think there should be restrictions on driving and getting jobs in epilepsy patient. Public awareness and educational campaigns should be included in modern methods of education to develop well-knowledged community, which will improve the quality of life of epileptic patients.

Epilepsy-related concerns among patients with epilepsy in West China

PURPOSE

In the present study, we aimed to investigate patient-derived epilepsy-related concerns among Chinese individuals with epilepsy and the impact of seizure control on patient concerns.

METHODS

All adult patients with epilepsy who had visited the outpatient clinic at West China Hospital between July 2014 and June 2016 were invited to participate in the study. All patients were given a blank sheet of paper and asked to list any concerns they had regarding their disease in order of importance. Demographic and clinical characteristics were also evaluated while regression models were used to examine the impact of seizure control on patient concerns.

RESULTS

A total of 1040 patients reported 2202 concerns across 25 distinct categories. The most frequently listed concerns were worries about seizures (55.4%), maintaining a job (17.4%), and the heritability of epilepsy (16.0%). The legal right to drive was listed by only 3.5% of patients who took the survey while seizure recurrence was described by participants as the most important concern (379, 36.4%). Compared with the group with uncontrolled seizures, the group with controlled seizures reported less frequently about "holding down a job" (odds ratio (OR): 0.333 (0.187-0.591)), "fear of being injured during a seizure" (OR: 0.353 (0.183-0.682)), and "leading a normal life" (OR: 0.452 (0.234-0.871)), but they reported more frequently about "having another seizure" (OR: 2.447 (1.614-3.710)), "problems with medication side effects" (OR: 1.733 (1.148-2.616)), and their "legal right or ability to drive" (OR: 2.360 (1.094-5.092)).

CONCLUSION

Our findings indicated that Chinese adults with epilepsy had various concerns, some of which differed from those observed in Western populations. Concerns about heritability of seizures, marriage, and pregnancy were of greater concern to Chinese patients compared with Western patients while the legal right to drive appeared to be less of a concern to Chinese patients. Patients with controlled seizures may still have many concerns. Chinese physicians should monitor patient concerns even among those whose seizures remain controlled to meet their needs. More time and attention should be given to address these issues in clinical practice in the context of Chinese culture.

Understanding the self-management skills of persons with epilepsy

PURPOSE

To determine whether the self-management skills of persons with epilepsy (PWE) vary across the different domains of the Epilepsy Self-Management Scale (ESMS).

METHODS

172 PWE completed a survey questionnaire as well as the ESMS.

RESULTS

Using ANOVA with pairwise comparison, the mean item scores of the medication, seizure, and safety management subscales of the ESMS were significantly higher than the lifestyle and information management subscales (p<0.01). The mean item score for the lifestyle management subscale was significantly higher than the information management subscale (p<0.01).

CONCLUSION

PWE in our population performed differently across the various domains of the ESMS and did worse on the lifestyle and information management subscales. We discuss the implications of this on patient counseling and education.

An internet forum analysis of stigma power perceptions among women seeking fertility treatment in the United States

Infertility is a condition that affects nearly 30 percent of women aged 25-44 in the United States. Though past research has addressed the stigmatization of infertility, few have done so in the context of stigma management between fertile and infertile women. In order to assess evidence of felt and enacted stigma, we employed a thematic content analysis of felt and enacted stigma in an online infertility forum, Fertile Thoughts, to analyze 432 initial threads by women in various stages of the treatment-seeking process. We showed that infertile women are frequently stigmatized for their infertility or childlessness and coped through a variety of mechanisms including backstage joshing and social withdrawal. We also found that infertile women appeared to challenge and stigmatize pregnant women for perceived immoral behaviors or lower social status. We argue that while the effects of stigma power are frequently perceived and felt in relationships between infertile women and their fertile peers, the direction of the enacted stigma is related to social standing and feelings of fairness and reinforces perceived expressions of deserved motherhood in the United States.

Employability among people with uncontrolled seizures: An interpretative phenomenological approach

PURPOSE

This study aimed to explore positive and negative factors affecting the employability in patients with uncontrolled seizures.

METHOD

Semistructured interviews with 21 patients with uncontrolled seizures were analyzed using interpretative phenomenological analysis.

RESULT

Eleven (52.4%) of the participants interviewed were employed; 7 were holding full-time position with more than 4years of working experience. The mean age was 34.6years, 71.4% were female, 38% were married, 71.4% had at least 11years of education, 38% had a driving license, 19% received government monetary aid, 66.7% had seizure onset before reaching 17years of age, 66.7% experienced monthly seizures, and 76% were on polytherapy. A total of 6 main themes were found to be affecting the employability among people with uncontrolled seizures: (a) ability to work; (b) intention to work; (c) support and stigma at workplace; (d) family support, overdependence, and protection; (e) life event; and (f) government and welfare support. Subthemes under the main theme ability to work included education, cognitive and physical functions, ability to continue working after seizures, ability to travel to work, self-perceived ability to work, and ability to cope with stress. Many shared the same idea that employment is important, but their intention to work varied. The employed group tended to work for a future goal and self-satisfaction, and the unemployed group tended to have no or lack intention to work. Positive factors were noted in the following themes: ability to work; intention to work; support and stigma at workplace; and family support, overdependence, and protection.

CONCLUSION

There were internal and external factors affecting the employability among people with uncontrolled seizures both positively and negatively. Positive internal factors such as ability and intention to work require further exploration.

The societal integration of individuals with epilepsy: perspectives for the 21st century

Epilepsy is a common neurologic disorder seen throughout the world. Advances in therapy have made it possible for persons with epilepsy (PWEs) to have improved seizure control and a better quality of life. However, it is not entirely clear whether this has resulted in their successful integration into society. This review examines the societal integration of PWEs, identifying both the progress made and the challenges that continue to hamper further advances. In general, PWEs are more integrated in western-oriented cultures. However, there continue to be ongoing difficulties due to poor education and intellectual functioning, poor social and family support, the undertreatment of coexisting psychiatric conditions, transportation and mobility limitations, and problems obtaining employment. This review also discusses the effects of low socioeconomic status on integration and the persisting prejudices that affect certain racial groups. Most importantly, this review underscores the fact that societal stigma towards PWEs is still very much alive. At the beginning of the 21st century, PWEs still encounter difficulties in their quest for full societal integration. Along with medical advances being made to improve seizure control, much still has to be done to bring about the reforms necessary to help PWEs live more meaningful and productive lives.

Is antiepileptic drug withdrawal status related to quality of life in seizure-free adult patients with epilepsy?

PURPOSE

This study aimed to determine factors that influence the quality of life (QOL) of seizure-free adult patients with epilepsy in western China and address whether these determinants vary by antiepileptic drug (AED) withdrawal.

METHODS

A cross-sectional study was conducted in the epilepsy outpatient clinic of West China Hospital, Sichuan University. Patients with epilepsy who were aged at least 18years and seizure-free for at least 12months were interviewed using the Quality of Life in Epilepsy Inventory-31 (QOLIE-31); the National Hospital Seizure Severity Scale (NHS3); the Liverpool Adverse Events Profile (LAEP); the Social Support Rating Scale (SSRS); the Family Adaptation, Partnership, Growth, Affection, and Resolve (APGAR) Questionnaire; and the Scale of Knowledge and Attitudes Toward Epilepsy. Eligible patients were divided into two groups: the nonwithdrawal group and the withdrawal group. The independent-samples t-test was used to compare the QOL between the groups, and linear regression analysis was used to explain the variance of their QOL.

RESULTS

One hundred and eighty-seven (135 nonwithdrawal and 52 withdrawal) patients were included in the analysis. The QOLIE-31 overall score of the nonwithdrawal group was lower than that of the withdrawal group (p<0.01). The LAEP score was the strongest predictor of the QOLIE-31 overall score of all subjects, explaining 26.9% of the variance. The second strongest predictor was the SSRS score, explaining 12.9%, and the other predictors were the NHS3 score (5.2%), education level (2.3%), age (1.5%), and marriage (1.0%). Furthermore, the strongest predictors in the nonwithdrawal group were the LAEP and SSRS scores, while in the withdrawal group, the strongest predictors were stigma scores and employment.

CONCLUSION

Among the seizure-free adult patients with epilepsy, those with AED withdrawal experienced better QOL than those continuing AED treatment. Furthermore, the determinants of QOL varied by AED withdrawal. Individual strategies to optimize QOL should be developed based on these differences.

Epilepsy: What do health-care professionals in Riyadh know?

PURPOSE

The objective of this study was to report on the knowledge of epilepsy, as well as attitudes and practices toward individuals with epilepsy, among health-care professionals in Riyadh, the capital city of Saudi Arabia.

METHODS

A survey consisting of 23 questions pertaining to epilepsy awareness was distributed to health education workers (n=51), nutritionists (n=56), physicians (n=265), dentists (n=58), pharmacists (n=41), nurses (n=224), physiotherapists (n=65), and fifth-year medical students (n=62) in three tertiary hospitals in Riyadh.

RESULTS

Of the 822 respondents who completed the questionnaire, 100% had heard about epilepsy, and 92.6% would allow their children to interact with an individual who has epilepsy. However, 67% of respondents would not want their children to marry an individual with epilepsy, 97.9% of respondents believed that individuals with epilepsy should have the same employment opportunities as the general population, 10.5% believe that supernatural power is the cause of epilepsy, 67.2% did not know how to deal with an individual experiencing an epileptic episode, and 56% did not know that surgery was a treatment option for individuals with epilepsy in Saudi Arabia. Of the 822 respondents, 39% would not abide by a physician's advice not to operate a motor vehicle because of their illness, 91% of whom cited problems with the public transportation system as a reason for disregarding the doctor's advice. When asked if the participants had access to any information on how to deal with epilepsy during their professional training, 60.3% had access to such information during their graduate studies. Ninety-eight percent of those with access to this information were physicians and health-care educators (p<0.001). Physicians and health-care educators were significantly more aware of epilepsy than any of the other groups.

CONCLUSION

The level of epilepsy awareness among health-care professionals in Riyadh needs improvement.

Impact of epilepsy on employment in Malaysia

INTRODUCTION

Studies on the impact of epilepsy on employment have been extensively performed in European and some Asian countries but not in Southeast Asia such as Malaysia, a country with a robust economy, low unemployment rate, and minimal social security benefits for the unemployed. This study aims to determine the impact of epilepsy on employment in Malaysia.

METHODS

Two hundred fifty subjects (52.4% male) with a mean age of 35.2 years were recruited from a tertiary neurology clinic in Malaysia.

RESULTS

Of the 250 subjects, 69.6% were employed full-time, 10.4% employed part-time, and 20.0% unemployed. Furthermore, 42.8% had a monthly income below poverty line, i.e., RM1000 (USD 320). Unemployment was associated with female gender, lower education level, younger age of seizure onset, less responsiveness to first antiepileptic drug (AED), higher seizure frequency and less seizure freedom, and higher total score in seizure severity scale. The age of onset (p=0.017), total score in the seizure severity scale (p=0.018), and the responsiveness to first AED (p=0.045) were the significant predictors of unemployment. Patients with part-time employment had similar education level with those who were unemployed, but they are more likely to be male and married, with intermediate age of seizure onset and seizure severity but with higher seizure frequency. As compared to their age-matched siblings, the patients were more likely to be unemployed (OR 13.1), to be single, and to have lower education level and lower monthly income.

CONCLUSION

Patients with epilepsy have high unemployment rate in Malaysia despite a robust economy and minimal social security. Besides those who were unemployed, many were in part-time or low-income employment.

Research implications of the Institute of Medicine Report, Epilepsy Across the Spectrum: Promoting Health and Understanding

In March 2012 the Institute of Medicine (IOM) released the report, Epilepsy Across The Spectrum: Promoting Health and Understanding. This report examined the public health dimensions of the epilepsies with a focus on the following four areas: public health surveillance and data collection and integration; population and public health research; health policy, health care, and human services; and education for providers, people with epilepsy and their families, and the public. The report provided recommendations and research priorities for future work in the field of epilepsy that relate to increasing the power of data on epilepsy; prevention of epilepsy; improving health care for people with epilepsy; improving health professional education about epilepsy; improving quality of life for people with epilepsy; improving education about epilepsy for people with epilepsy and families; and raising public awareness about epilepsy. For this article, the authors selected one research priority from each of the major chapter themes in the IOM report: expanding and improving the quality of epidemiologic surveillance in epilepsy; developing improved interventions for people with epilepsy and depression; expanding early identification/screening for learning impairments in children with epilepsy; evaluating and promoting effective innovative teaching strategies; accelerating research on the identification of risk factors and interventions that increase employment and improve quality of life for people with epilepsy and their families; assessing the information needs of people with epilepsy and their families associated with epilepsy-related risks, specifically sudden unexpected death in epilepsy; and developing and conducting surveys to capture trends in knowledge, awareness, attitudes, and beliefs about epilepsy over time and in specific population subgroups. For each research priority selected, examples of research are provided that will advance the field of epilepsy and improve the lives of people with epilepsy. The IOM report has many other research priorities for researchers to consider developing to advance the field of epilepsy and better the lives of people with epilepsy.

Health perception and socioeconomic status following childhood-onset epilepsy: the Dutch study of epilepsy in childhood

PURPOSE

Epilepsy may have far-reaching consequences for patients, other than having seizures and medication. At 15 years after diagnosis, this study investigates health perception, restrictions due to epilepsy, living arrangements (including marital status and offspring), and the educational and occupational attainment of patients with childhood-onset epilepsy.

METHODS

A total of 453 patients with epilepsy had a 5-year follow-up since diagnosis with regular visits and data collection. Ten years later, a questionnaire addressing epilepsy was completed by 413 patients, resulting in a mean follow-up of 15 years. Subjects were compared with age peers of the Dutch population for each etiologic group separately, and also for subjects with/without a 5-year terminal remission regardless of treatment. Age-adjusted standardized incidence rates were calculated for each variable.

KEY FINDINGS

Subjects with normal intelligence had a health perception comparable with that of the general population, but significantly more subjects without remission had a worse health perception, especially those still using medication. Restrictions and symptoms due to epilepsy were reported by 14% of the subjects, mainly by those without remission or with ongoing medication. The living arrangement of subjects with idiopathic or cryptogenic etiology was similar to that of Dutch persons of the same age (age peers). Subjects with remote symptomatic etiology less often lived independently or with a partner, and more frequently resided in an institution or living group for the disabled. Those with and without remission were more often part of another household, mainly due (in both groups) to having a remote symptomatic etiology. Rates of having a partner and offspring were significantly reduced only for subjects with remote symptomatic etiology. Fewer students with idiopathic/remote symptomatic etiology and students in remission followed higher vocational or scientific education. In these latter groups, the highest attained education of employees was lower than expected. The employment status of subjects with idiopathic or cryptogenic etiology was comparable with that of their Dutch age peers, but fewer subjects with remote symptomatic etiology were employed and more of them were part of the dependent population. However, for those in the labor force (employed/unemployed) all employment rates were ≥90%, even for those with remote symptomatic etiology. Nevertheless, fewer employees than expected had a higher vocational or scientific level of occupation, even those with idiopathic etiology and those in remission.

SIGNIFICANCE

Health perception, living arrangement, and socioeconomic status were influenced by epilepsy, comorbidities, or treatment, particularly for subjects with remote symptomatic etiology or no remission. The group in remission fared less well than expected, mainly due to the numbers of subjects with remote symptomatic etiology in this group. In line with others, we conclude that childhood-onset epilepsy is associated with lower educational attainment, even for subjects with idiopathic etiology and subjects in remission; probably related to this, their occupational level was also lower than expected.

Socio-occupational and employment profile of patients with epilepsy

OBJECTIVE

Epilepsy has a significant impact on quality of life. Many studies have observed higher unemployment rates among patients with epilepsy. However, unemployment rates vary according to the clinical conditions, country, and group studied.

METHODS

Between October 2007 and February 2008, we performed a cross-sectional multicenter epidemiological study to evaluate the socio-occupational and employment profiles of 872 adult patients with epilepsy followed in outpatient epilepsy clinics in Spain.

RESULTS

Fifty-eight percent of the patients were employed at the time of the survey, 10.9% of the patients were unemployed, and 12.5% were occupationally incapacitated.

CONCLUSION

Patients with epilepsy had employment rates similar to those of the general population, and slightly higher levels of unemployment. The main factors associated with unemployment and incapacity were the presence of refractory epilepsy, the occurrence of a seizure in the last 12 months, level of education, and polytherapy.

A multi-dimensional approach to the transition of children with developmental disabilities into young adulthood: The acquisition of adult social roles

PURPOSE

To test the hypothesis that the difficulties young adults with developmental disabilities have in obtaining adult social roles are not inevitable consequences of their childhood impairment. We used the conceptual framework of the International Classification of Functioning, Disability, and Health to test this hypothesis.

METHOD

We used a structured questionnaire to obtain information on the consequences of childhood impairment in young adulthood and to examine the relationship between impairment and acquisition of adult social roles. The sample (n = 635) came from the Metropolitan Atlanta Developmental Disabilities Follow-up Study of Young Adults, a population-based cohort of young adults aged 21 - 25 years identified at age 10 with childhood impairment.

RESULTS

The results suggest that: (i) attaining adult social roles varies by impairment type and severity, (ii) experiencing activity limitations partially mediate the relationship between impairment and adult social roles, and (iii) attending postsecondary education increases the likelihood of attaining markers of adulthood.

CONCLUSIONS

Intervention to reduce activity limitations and to develop strategies to increase attendance in postsecondary education may increase the likelihood for the acquisition of adult social roles among young adults with childhood impairment.

Employment and quality of life in mesial temporal lobe epilepsy with hippocampal sclerosis: is there a change after surgical treatment?

PURPOSE: The aim of this study was to evaluate in patients with mesial temporal lobe epilepsy (MTLE) with hippocampal sclerosis (HS): (1) employment patterns before and three years after epilepsy surgery and their impact in Quality of Life (QOL); (2) demographic and clinical variables associated with employment. METHODS: Data from 58 patients with diagnosis of refractory MTLE with HS who had corticoamygdalo-hippocampectomy were analyzed. The subjects answered to Brazilian validated version of the Epilepsy Surgery Inventory (ESI-55) before, and three years after surgery. In a semi-structured interview, sociodemographic and clinical characteristics were obtained. Changes in employment after surgery were classified in one of the three categories: (i) improvement status: those who were unemployed, no-formal employed, students, housewives and subjects who have never worked to employed category; (ii) unchanged status: no change in occupation; this category included subjects who were employed before and after the surgery, housewives, students, and the group who remained unemployed, receiving ill-health benefits or retired after the surgical treatment; and (iii) worsened status: loss of employment. RESULTS: Employment status did not show any significant change after surgery: in 51(87.9%) it remained unchanged, in six (10.3%) it improved, and one patient (1.7%), who was employed before the surgery, retired after that. In a subgroup of 22 patients employed after surgery, ten (45.5%) were seizure-free, seven (31.8%) had only rare auras, and five (22.7%) had seizures. In the group of improvement, 12 patients (70.5%) had no-formal employment and five (29.5%) had a formal job before surgery. After three years, 14 (63.6%) of 22 subjects were formally employed. Our data suggested that the employability was strongly correlated (p<0.05) with a positive perception of health-related quality of life measured by ESI-55, before and after surgical evaluation. CONCLUSION: Our study demonstrated in a homogeneous group of MTLE with HS, a modest, but positive relationship between surgical outcome and work gain, and that QOL had strong correlation with the fact of being employed.

The contribution of seizures to psychosocial ill-health

Persons with a chronic health condition may be disadvantaged compared to others, though the precise pattern of disadvantage will vary from one condition to another. Persons with epilepsy have been shown to be at increased risk of both psychological morbidity and social disadvantage. Various clinical characteristics of epilepsy have been linked to these psychosocial risks, primary among which is seizure frequency: studies linking seizure frequency to psychosocial ill-health are reviewed here. Given the apparently powerful influence of seizure frequency, it is unsurprising that psychosocial health trajectories in epilepsy are very closely linked to its clinical course-but the relationship is not a completely linear one. Recent research has begun to unravel factors other than seizure frequency which appear promoting or protective of psychosocial ill-health. The need for a more nuanced approach to understanding the causes of psychosocial ill-health is highlighted, as is an important distinction between epilepsy as biomedically defined disease and as socially defined illness.

Labor market participation following onset of seizures and early epilepsy: Findings from a UK cohort

PURPOSE

Previous studies have reported a considerable employment disadvantage among people with epilepsy. In a cohort of men and women who had experienced a single seizure or had early epilepsy at study entry we explored employment status and social mobility over 4 years and investigated whether employment outcomes were more disadvantageous for certain social groups.

METHODS

Analyses were based on 350 individuals of working age identified via the UK Multicentre Study of Early Epilepsy and Single Seizures. Employment rates were calculated for the cohort and general population. Employment trajectories over 4 years were explored according to occupational social class. The relative risk of employment was calculated by clinical features of seizures and social class.

RESULTS

Individuals with single seizures or early epilepsy had significantly lower employment rates than the general population at study entry, and 2- and 4-year follow-up. Employment rates of men and women in the cohort did not differ significantly. Although little social class mobility occurred during follow-up, there was evidence of some downward mobility between first seizure(s) and study entry. In the fully adjusted model, nonemployment was predicted at all time points by having fair/poor self-rated health and experiencing four or more seizures. We observed that some individuals continued to work in hazardous occupations or drive professionally within a year of experiencing seizure(s).

DISCUSSION

People who have recently experienced a single seizure or who have early epilepsy are exposed to substantial employment disadvantage. Greater efforts are necessary to help these people return to work and stay employed.

Quality-of-life trajectories in epilepsy: a review of the literature

The potential psychosocial sequelae of epilepsy are well-documented, but it cannot be assumed that trajectories for quality of life (QOL) of people with epilepsy will inevitably follow its clinical course. In this article, we draw on available literature to suggest likely QOL trajectories associated with epilepsy and the broad range of disease-, patient-, and other-focused factors that appear important in determining them. We conclude that both the likely shape and time frame for QOL trajectories associated with particular clinical scenarios can be delineated, but that their shape can be altered by a much wider range of factors than those represented as epilepsy disease progression. We identify contributory factors currently relatively unexplored and highlight implications for treatment and areas for future research.

Health disparities in epilepsy: how patient-oriented outcomes in women differ from men

Epilepsy is a chronic disorder with multiple effects on biological, social, and psychological health. Many of these effects differ between men and women, but only sparse research has specifically addressed the relevance and importance of the differences. Available evidence suggests that men and women with epilepsy have differing rates of employment and driving, and women with epilepsy have increased risk for specific mood disorders such as post-partum depression. National surveys of physicians indicate that many physicians providing care for women with epilepsy have limited knowledge of fundamental concerns such as interactions between antiepileptic drugs and oral contraceptives, and their potential teratogenic effects. Further research and clinical implementation of improved gender-specific care is needed to optimize outcomes for women with epilepsy.

Epilepsy and employment: literature review

OBJECTIVE

The aim of this review is to increase understanding of the factors that affect the regular employment positions of people with epilepsy by means of the World Health Organization International Classification of Functioning, Disability, and Health (ICF) model.

METHOD

Thirty-four primary research articles describing factors associated with employment for people with epilepsy are reviewed.

RESULTS

People with epilepsy may face a number of complex and interacting problems in finding and maintaining employment. Stigma, seizure severity, and psychosocial variables such as low self-esteem, passive coping style, and low self-efficacy have been implicated as factors that play an important role in predicting employment. Findings demonstrate the need for specific employment training programs.

CONCLUSION

We recommend specific training interventions that focus on increasing the self-efficacy and coping skills of people with epilepsy so that these individuals will be able to accept their disorder and make personal and health-related choices that help them to achieve better employment positions in society.

Clinical characteristics associated with psychosocial functioning among patients with uncomplicated epilepsy in Spain

OBJECTIVE

To identify the clinical characteristics associated with poor psychosocial functioning among Spanish patients with epilepsy but no other neurological or psychiatric disorder.

METHODS

Between May and September 2001 a survey among patients with epilepsy was carried out in 32 Spanish health care centres. The selection criteria of patients were attendance to a routine neurologist visit, to be aged between 25 and 64 and not having another additional neurological handicap (n=812). Psychosocial function was elicited through six indicators: educational level, marital status, unemployment status, restricted car driving, self-perception of epilepsy as an important limiting factor in the educational level achieved and, among unemployed, as the cause of their unemployment. Multiple logistic regression models were fitted in order to calculate adjusted odds ratios (aOR) and their 95% confidence intervals.

RESULTS

After simultaneously adjusting for socio-demographic variables and clinical characteristics, the six outcomes analysed increased with seizure frequency. Moreover, all the outcomes except low educational level were also related to early age at onset of epilepsy. Although no relation with objective educational level was found, there was a strong association between early age at onset of symptoms and self-perception of epilepsy as an important limiting factor of educational achievement.

CONCLUSION

These findings emphasize the need for more effective treatment of epilepsy and also highlight the importance of a psychosocial approach to management of epilepsy for patients with an early onset of symptoms in order to prevent social limitations in adult life.

Employment concerns of people with epilepsy in Kerala, south India

We examined current employment status, reasons for unemployment, and related psychosocial concerns of 202 persons with epilepsy from the south Indian state of Kerala. Compared with 19% of the general population, 58% of persons with epilepsy were unemployed. Seizure remission for > or = 2 years, monotherapy, better education, ability to travel alone, and ability to drive were significantly associated with being employed. More than three-fourths of the persons with epilepsy had disclosed their epilepsy to their employers and co-workers, which did not adversely affect employment for the majority. The unemployed perceived fear of having seizures and seizure-related falls in the workplace, inadequate education, and antiepileptic drug-induced fatigue as reasons for unemployment. We conclude that unemployment is a major concern of people with epilepsy in this developing region. In addition to optimum seizure control, persons with epilepsy need support in job seeking, in reducing fear of seizures and falls in the workplace, and in identifying their individual abilities and limitations.

Factors associated with employment in epilepsy patients

OBJECTIVE

The aim of the study described here was to determine those variables associated with employment in patients followed at a level 4 epilepsy center.

METHOD

A survey was sent to patients seen at the University of Florida Health Science Center/Jacksonville Comprehensive Epilepsy Program.

RESULTS

Two hundred sixty-two eligible subjects constituted the study population. By univariate analysis, variables that distinguished employed patients included: younger age, Caucasian race, higher education and household income, not receiving disability benefits, currently studying, fewer seizure medications, having no other medical conditions that interfere with work, previous work experience, perceived importance of work for personal and financial reasons, and decreased fears of workplace discrimination. By logistic regression, higher annual family income, perceived importance of work for personal reasons, and decreased fears of workplace discrimination were the only variables independently associated with employment.

CONCLUSION

Psychosocial factors such as a high self-perceived importance of work and decreased fears of workplace discrimination are significantly associated with employment in epilepsy patients.

Employers' attitudes to employment of people with epilepsy: still the same old story?

PURPOSE

One area of life quality known to be compromised by having epilepsy is employment, and one factor contributing to the employment problems of people with epilepsy (PWE) is employer attitudes. Much research on this topic is now outdated and given the changing legal, medical, and social contexts in which PWE live, we therefore reexamined employer attitudes in the United Kingdom.

METHOD

A mail survey of a random sample of U.K. companies selected to be representative of the 14 U.K. economic regions and proportional to the number of employees.

FINDINGS

The overall response rate was 41% (n = 204). Twenty-six percent of respondents reported having experience of employing PWE. Sixteen percent considered that there were no jobs in their company suitable for PWE; 21% thought employing PWE would be "a major issue." Employers were uniformly of the view that PWE, even when in remission, should disclose their condition to a prospective employer. Seizure severity, frequency, and controllability were all considered important features of epilepsy in the context of employment. Epilepsy created high concern to around half of employers, including the likelihood of it being linked to a work-related accident. Employers were willing to make accommodations for PWE, in particular job sharing, temporary reassignment of duties, and flexible working hours. Attitudes to employment of PWE were influenced by company size and type and previous experience of doing so.

CONCLUSIONS

We conclude that it is still the same old story for employers' attitudes toward PWE, though happily for PWE, with some room for optimism.

Ultimate success in epilepsy - the patient's perspective

Most people with epilepsy can live outwardly normal lives, but fear about impending seizures, driving restrictions, lack of independence, employment and social problems, medication-related adverse effects and the presence of cognitive or psychiatric complications are all concerns readily identified by affected individuals. While seizure control is the overriding goal of treatment, it is essential to realize the importance that patients place on other aspects of daily functioning. While many of the concerns identified by patients can only be managed by improved social support, others (e.g. neuropsychological impairment, medication-related adverse events, cognitive impairment, sleep disturbance) may be amenable to therapy (if available) or to the selection of a more appropriate antiepileptic drug. Each antiepileptic drug has a unique pharmacodynamic and tolerability profile. Awareness by the treating clinician of the pharmacological profile of each drug may help to minimize unwanted treatment-related effects and possibly improve the outcome of treatment from an epilepsy patient's perspective. Therefore, in order to achieve true treatment success, clinicians need to understand how individuals perceive their disorder and, where possible, address those factors that adversely affect patient quality of life. For the person with epilepsy, successful treatment involves beneficial effects on social, vocational and psychological function. This extends beyond seizure control to freedom from the fear associated with seizures, confidence in pharmacological therapy and improvements in health-related quality of life.

Quality of Life of People with Epilepsy in Iran, the Gulf, and Near East

PURPOSE

To study the impact of epilepsy and its treatment on the quality of life of people living in Iran and in countries in the Gulf and Near East.

METHODS

Clinical, demographic, and psychosocial details were collected through the use of a self-completed questionnaire distributed to patients attending hospital outpatient clinics.

RESULTS

Data were collected from 3,889 people with epilepsy from 10 countries. More than 40% of all respondents had frequent seizures, and reported levels of side effects from medication were high, the most commonly reported being nervousness, headaches, and tiredness. A significant number of respondents reported changing their medications because of side effects or poor seizure control. Respondents reported that epilepsy and its treatment had a significant impact on a number of different aspects of their daily lives. A significant number of respondents felt stigmatized by their epilepsy. Reported health status was reduced when compared with that of people without epilepsy, particularly for physical and social functioning and energy and vitality, as assessed by using a generic health status measure, the SF-36.

CONCLUSIONS

This is the largest study to date documenting the impact of epilepsy and its treatment in Iran, the Gulf, and Near East regions. Differences were found between the quality-of-life profiles of respondents in this study and those who participated in an earlier parallel study in Europe.

Reaction to epilepsy in the workplace

PURPOSE

The purpose of this study was to determine the characteristics of epilepsy that produce avoidant behavior in the workplace and therefore contribute to the actual stigma that persons with epilepsy are subjected to on the job.

METHODS

We developed a survey consisting three vignettes briefly describing a coworker with either depression, multiple sclerosis, or epilepsy. Each vignette was followed by eight identical questions addressing the level of comfort during interactions with the vignette subject. The epilepsy vignette did not describe a seizure. The surveys were hand-distributed in two companies in New York City and returned anonymously by mail. The results of the responses to each illness were compared by chi2, and the responses were correlated with demographic information by using Pearson's correlation.

RESULTS

Seventy-four of 200 distributed questionnaires were returned. Respondents reported more anxiety at the thought of interacting with a coworker with epilepsy than with depression or multiple sclerosis, but this difference did not reach significance. Worry about sudden, unpredictable behavior for the coworker with epilepsy was significantly greater than that with multiple sclerosis (p = 0.014). The level of comfort regarding providing first aid for the coworker with epilepsy was significantly less (p = 0.018) than that for depression and multiple sclerosis. Lower job level and lower income level correlated with more social discomfort for all three illnesses.

CONCLUSIONS

The idea of a having a coworker with epilepsy may produce some social avoidance. However, the worry about a sudden, unpredictable event and the discomfort regarding providing first aid for a coworker with epilepsy is significant when compared with that with depression or multiple sclerosis. These findings suggest that education about first aid for epilepsy will reduce the worry and discomfort surrounding persons with epilepsy in the workplace.

Comprehensive Care of the Epilepsy Patient-Control, Comorbidity, and Cost

Traditionally, control of seizures in patients with epilepsy is viewed as the most important clinical outcome. Yet, current antiepileptic drugs (AEDs) do not always achieve this. Around 30-40% of patients remain uncontrolled despite pharmacological intervention. Poor tolerability of AEDs is a large part of the problem and contributes as much to the overall effectiveness of therapy as efficacy. Comorbid conditions are present in many patients, and appropriate management of these can further improve seizure control and quality of life. Patients with epilepsy often experience--among other disorders--neuropsychological effects, migraines, and psychological problems (especially anxiety and depression). Sleep disturbances are also common and have been shown to contribute to the intractability of seizures in some patients. Many anticonvulsant treatments have the potential to improve--or in some cases worsen--these concurrent conditions, and these properties should therefore be considered in the total care of the patient. Finally, the costs of uncontrolled epilepsy are measured not only in terms of direct healthcare-related costs, but also in terms of lost productivity and opportunity. The indirect costs of epilepsy are substantial and account for 70-85% of total disease-related costs. Patients with uncontrolled seizures contribute disproportionately to healthcare costs, reinforcing the need for the development of newer AEDs with improved profiles of efficacy and tolerability, but with minimal adverse effects on behavior, cognition, and sleep.

Validation of the quality of life in childhood epilepsy questionnaire in American epilepsy patients

The aim of this study was to adapt the Australian Quality of Life in Childhood Epilepsy Questionnaire (QOLCE) and determine its psychometric properties in a North American population. Participants were North American families with children diagnosed with epilepsy. Parents were asked to complete the American QOLCE (USQOLCE) and the Child Health Questionnaire (CHQ). Seventy-one families completed the USQOLCE. The internal consistency reliability of the subscales was good. USQOLCE subscales correlated highly with theoretically similar subscales contained in the CHQ. Theoretically dissimilar subscales on the two instruments did not correlate as well. USQOLCE correlated significantly with a parental rating of seizure severity and an independent measure of degree of postoperative seizure control. This study demonstrated that the USQOLCE is suitable for a North American population with evidence of its reliability and validity including its sensitivity to seizure burden.

Influence of clinical, demographic, and socioeconomic variables on quality of life in patients with epilepsy: findings from Georgian study

OBJECTIVE

To identify the clinical, demographic, and socioeconomic factors that are associated with a poor quality of life in patients with epilepsy in Georgia.

METHODS

Clinical, demographic, and socioeconomic status data were collected from 115 adult epileptic outpatients being treated in the epilepsy programme at the Sarajishvili Institute of Neurology and Neurosurgery (SINN) in Tbilisi, Georgia. Health Related Quality of Life (HRQL) was measured by the Quality of Life in Epilepsy Inventory (QOLIE-31). Multiple regression analysis was used to determine which variables were associated with QOLIE-31 total and subcomponent scores.

RESULTS

Mean age of the patient population was 37.9 (SD 15.8) years; 43.5% were females; 51.8% did not have a partner; 39.1% had some university education; 82.6% were unemployed. Of 115 epileptic patients 83.3% had partial, and 16.7% had generalised seizures. Overall, 32.2% of patients were seizure free, and 28.7% experienced more than 10 seizures over the past year. The variables that most strongly predicted a lower QOLIE-31 total score were a low education level, high seizure frequency, and long duration of epilepsy. The QOLIE-31 all subcomponent scores correlated strongly with seizure frequency. Advanced age was a significant predictor for a low overall quality of life, energy/fatigue, and cognitive scores. Female sex was the factor that significantly predicted a low seizure worry score. Education level strongly correlated with overall quality of life, and cognitive and social functioning scores.

CONCLUSIONS

Clinical factors such as high seizure frequency and long duration of epilepsy had a significant influence on HRQL. Advanced age, female sex, and a low education level were the demographic factors that correlated strongly with low quality of life scores.

Cognitive behaviour therapy with adults with intractable epilepsy and psychiatric co-morbidity: preliminary observations on changes in psychological state and seizure frequency

Cognitive behaviour therapy (CBT) was undertaken with six adults with chronic, poorly controlled seizures and co-existing psychiatric and/or psychosocial difficulties. During 12 sessions of CBT from an experienced CBT Nurse Specialist, treatment focused concurrently on epilepsy-related problems, associated psychopathology and on the development of psychological strategies to reduce seizure occurrence. At the end of treatment participants rated their initial epilepsy-related problem as having less impact on their daily lives and at one-month follow-up reported less deleterious impact on everyday life in terms of their psychological difficulties. In addition participants demonstrated significant improvements in terms of their self-rated work and social adjustment, and in their decreased use of escape-avoidance coping strategies. These positive findings occurred despite the absence of a significant decrease in seizure frequency. Issues raised by the complexity and severity, both of these patients' psychological/psychosocial difficulties and their epilepsy, are discussed in relation to the optimal length of treatment that may be required when adopting a CBT model in this patient group.

Socioeconomic prognosis after a newly diagnosed unprovoked epileptic seizure in adults: a population-based case-control study

PURPOSE

To investigate the socioeconomic prognosis after a newly diagnosed unprovoked epileptic seizure in adults.

METHODS

Sixty-three patients 17 years or older with a newly diagnosed unprovoked epileptic seizure from 1985 through 1987 and 107 sex- and age- matched controls were followed up for 10 years to 1996. Studied variables were income, source of income, sickness periods, incapacity rate, diagnosis-specific incapacity rate, vocational status, and education.

RESULTS

Relative growth of income was similar between patients and controls during follow-up. Patients had lower income than did controls 2 years before seizure onset and during the entire follow-up. This was related to higher morbidity among patients, as measured by sickness periods and incapacity rate. Employment rates did not evolve negatively among patients after seizure onset and were close to employment rates of controls during follow-up time. There was no difference between patients and controls regarding education.

CONCLUSIONS

After a newly diagnosed unprovoked epileptic seizure in adults, no negative development regarding employment and education occurs. Income development is positive unless refractory seizures evolve. However, income is lower among patients with epilepsy than among controls, and this difference can be related to overall morbidity.

Impacto da epilepsia no trabalho: avaliação da qualidade de vida

Este estudo teve como objetivo reconhecer quais os fatores mais afetados na qualidade de vida (QV) de pacientes com epilepsia. Foram avaliados 134 sujeitos com diagnóstico de epilepsia, aleatoriamente selecionados no Ambulatório de Epilepsia do HC/UNICAMP, com idade entre 18 e 59 anos (M=35,38; DP=9,86), através do "Questionário de Qualidade de Vida 65". A maioria dos sujeitos possuía ensino fundamental incompleto (58,2%), não trabalhava (69,4%) e era solteiro (48,5%). O trabalho foi a área considerada mais prejudicada pela epilepsia (31,29%), o que reforça estudos que comprovam o alto índice de desemprego ou subemprego na população epiléptica e atenta para a importância da inserção no mercado de trabalho como um fator de integração social, econômica, e de realização pessoal.

Epilepsy in Estonia: a quality-of-life study

PURPOSE

To study the impact of epilepsy and its treatment on people with epilepsy in Estonia and to analyze how it is affected by the characteristics of epilepsy.

METHODS

Clinical and demographic data about patients were obtained from medical notes and mailed self-completed questionnaires (including the RAND 36-Items Health Survey 1.0 (RAND-36)).

RESULTS

Information was collected from 203 patients aged 20-74 years, who all had active epilepsy. A third of the respondents had been seizure free during the last year. Eighty-four percent were receiving monotherapy. More than half of respondents felt stigmatized by epilepsy, 24.7% of them highly so. A third were working full-time, 31.9% were underemployed workers, and 11%, unemployed. Sixty-two percent of these same unemployed or underemployed workers considered their epilepsy to be a significant reason for this situation. Overall, 44% believed they had been treated unfairly at work or when trying to get a job. Study respondents scored lower in all domains on the RAND-36 than did persons from the control group. The biggest differences were found in five domains: Social functioning, Role limitations-physical, Role limitations-emotional, General health, and Vitality.

CONCLUSIONS

The clinical characteristics of this study were similar to those of most other series of prevalence cases of epilepsy. The level of employment among persons with epilepsy was not lower than that in the general population. The percentage of stigmatization was high. There were significant differences in the way respondents scored on the stigma scale and on the RAND-36 domains when measuring their health status, depending above all on seizure frequency and type.

The attitude of courts in England to compensation for post-traumatic epilepsy

The attitudes of courts in England to the assessment of damages for post-traumatic epilepsy have dramatically changed over the last 20-30 years. In assessing damages for post-traumatic epilepsy the courts are faced with a number of considerations: epilepsy can appear several years after the injury; epilepsy is not a homogeneous condition; the eventual prognosis is unknown; the epilepsy may not have been directly due to the trauma; and epilepsy affects life expectancy and employment. Damages were originally fixed at the point of compensation, and these rather crude calculations led to both over- and under-compensation. This situation was improved in 1985, when courts were permitted to award damages on the assumption that epilepsy would not occur or worsen, and further damages should these assumptions prove to be incorrect. The courts in England still depend, however, upon the evidence of expert witnesses chosen by the plaintiff and defendant. A tension thus exists between the duty of expert witnesses to the court and the understandable inclination of expert witnesses to support the party that has instructed them. The Woolf report has led to changes in the responsibilities of expert witnesses, and will hopefully remedy many of the inconsistencies and inequities that occur.